HomeMy WebLinkAboutBUSINESS PLAN
SITE/FACILITY D I AGRAI~ FORM
NORTH SCALE: BUS INESS NAME: I FLOOR: OF
DATE:'" / FACILITY NAME: UNI'~- o ~: OF-.-,
(CHECK ONE) SITE DIAGRAM ~ FACILITY DIAGR.'~
(Ins'0eetor's Comments): -OFFICIAL USE ONLY-
- 5A -
S[~E DIAGRAM (Requlrl :ems)
I. Address: Identify the 9. Lock (key) Box
principle buildings
by the Street numbers. 10. MSDS Storage Box
2. Street(s), Alleys, 11. Railroad Tracks
Driveways, and Parking
Areas adjacent to the 12. Fence or Barrier
property. Include the a. Wire
street names.
b. Masonry
3. Storm Drains, Culverts.
Yard Drains c. Wood
4. Drainage Canals, Ditches, d, Gates
Creeks,
13. Powerllnes
S. Buildings
a. Frame construction · ,, · .. ,- .14. Guard Station
b. Masonry construction 15 Storage Tanks:
Identify the
c. Metal construction capacity in gal.
., .,'- '.~:, ,... .-. ... ~ :-~ .... ' , : .'.......' .- ..... ~ ., ..a, Above ground, , · ,'. .... '...' -.'. ,....'
d. Access Door
a. Gas 16. Diking or Berm
b. Electricity 17. Evacuation Route
- c. Water 18. Evacuation Area:
Identify the
7. Fire Suppression Systems: location where
a. Fire Hydrants employees will
meet.
b. Fire sprinkler 19. Outside Hazardous
Connections Waste Storage
c. Fire Standpipe 20. Outside Hazardous
Connections Material Storage
. d. Water Control Valves '. 21. Outside Hazardous .'
Use/Handling "
e. Fire Pump 22. Type of Hazardous
.Material/Waste
Stored
8. Fire Department Access or Used (See
Below)
TYPE OF HAZARDOUS MATERIAL
F = Flammable E = Explosive L = Liquid R = Radtologlcal
C = Corrosive 0 = Oxidizer O ~ Gas P = Poison
Water Reactive T = Toxic S = Solid H = Cryogenic
.D = Waste B = Etiological
Example: Flammable Liquid = FL
FACILITY DIAGRAM (Required Items in addition to the above)
1. Risers for Sprinklers 8. Fire Escapes
2. Partitions 9. Air Conditioning Units
3. Stairways: Indicate the 10. Windows
levels served from
highest to lowest. 11. Inside Hazardous Waste
Storage
4. Escalator: Indicate the
levels served from 12. Inside Hazardous
highest to lowest. Materials Storage
5. Elevator 13. Inside Hazardous
Materials Use/Handling
6. Attic Access
14. Sewer Drain Inlets
BAKERSFIELD CITY FIRE DEPARTMENT
HAZARDOUS MATERIALS DIVISION
2130 "G" STREET
BAKERSFIELD, CA. 93301
HAZARDOUS MATERIALS MANAGEMENT PLAN
INSTRUCTIONS:
1. 7o avoid further .action, return this form within 30 days of receipt.
· 2. __~_PE/PRINT A~NS._W__E.R$ IN E_. N~LI~.~_SH_._ .. _
3, Answer the questions below for the business as a whole, -~[~.
4. Be brief and concise as po~ibte.
HAZ. MA% DiV.
SECT1ON 1' BUSINESS IDENTIFICATION DATA
LOCATION: //~ ~/~~,~ ~'
MAILING ADDRESS: //~ ~,'~~,~ ~~
CITY: ~/~J~,~ STATE:~ z~P9~¢¢ PHONE:
DUN & BRADSTREET NUMBER' SIC CODE:
SECTION 2: EMERGENCY NOTIFICATION:
.CONTACT TITLE BUS. PHONE 2'4 HR. PHONE
~. '-~.~/~,,,,., (~,~,,~. ~.,~-,-~.. 3~.~/--7~r-~ ~J~-~.7,_t~2~ ..
2.
'_ BakersfieLd Fize Dept. ·
HAZARDOUS MATERIALS MANAGEMENT PLAN
· .
SECTION 3: TRAINING:
NUMBER OF EMPLOYEES'
MATERIAL SAFETY DATA SHEETS ON FILE:
BRIEF SUMMARY oF TRAINING PROGRAM'
Glenn Reed l~t.
E-Z SMOG & PATS AUTO SALES
1129 California Ave. ~~¢~ ~
Bakers.eld, CA 9~04 (805) 324-78~ ~' ~ -- ~ ~- ~
SECTION 4: EXEMPTION R~UEST:
I CERTIFY UNDER PENALTY OF PERJURY THATMY BUSINESS IS EXEMPT FROM THE
~EEORTtNG REGU~REMENTS OF CHAPTER ~.~5 OF THE "CAUFORNIA HEALTH &
SAFETY CODE" FOR THE FOLLOWING REASONS:
WE OD NOT HANDLE HA~ROOUS MATERIALS.
~' WE DO HANDLE HA~ROOUS MATERIALS, 8UT THE QUANTITIES AT NO
TiMEEXCEED THE MINIMUM REPORTING GUANT~IES
.......... ~THE~2 (SPECIFY REASON)
SECTION 5~ CERTIFICATION:
MATION IS ACCURATE, I ~NOERSTANO THAT THIS' INFORMATION WILL BE USED TO
FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFE~ CODE"
ON HA~RDOOS MATERIALS (DIV. 20 CHAPTER 6.95 SEC, 25~00 ET AL.) AND THAT
.INACCURATE INFORMATION-CONSTITUTES PERJURY.
SIGNATURE TITLE DATE
~IM 472801
Account Number
ACCOUNTS RECEIVABLE ADJUSTMENT
January 15~ 1993
Date New Account
New Address
Valerle Pendergrass Close Account
From Service Chanae
Other Adjustments X
Fire Department - Hazardous Materials Division
.Department/Division
E-Z Smog] Lube & Tune
Billing Name
1129 California Ave
Billing Address
1129 California Ave
Site Address
Parcel # (If Applicable)
Landlord Name & Address (If Applicable)
ADJUSTMENT
Last Billed' Correct Billing Adjustment t° Effective Date of
Billing Change
$142.00 0 01/01/93
Approved By:
Remarks: Business stopped doing oll changes in January, 1992. Should have been no longer In
business. Billed in error.
page: 2 Account Billing/Collection Activity Inquiry SUTL108
Acct : 472801 Cyc St CL Bill St: NO Cyc: 5 Rt: Seq:
SSN : ~ Parcel: .... Svc Cls :e
Name : E-Z SMOG LUBE & TUNE
Svc Add: 1129 CALIFORNIA AVE
Readings Cons Prey Rdg Curr Rdg Cons
01/01/93 Amount Misc Transactions ~
Fwd: $150.93 Type Desc Date Amount Receipt #
Water: $0.00 B92 FINANCE CHARGE 02/01/92 0.16
Sewer: $0.00 Bgl PENALTY 03/01/92 13.50
Misc: $158.53 B92. FINANCE CHARGE 03/01/92 2.87
Cred: $-167.46 99 PAYMENT 03/11/92 -167.46 49534
Total: $142.00 F09. HAZ MAT HANDLING FEE 01/01/93 142.00
Enter '/' For More Billing History, 'D' For Detail Postings, '/C' for Credit and
Deposit History or 'XX' ~To Exit
ALT-F10 HELP I ADDS VP I FDX I 9600 E71 I LOG CLOSED I PRT OFF I CR I CR
1101 Mt. Vernon Ave.
Bakersfield, CA 93306 .
OFF~C:AL U8~ CNU/
HAZARDOUS MATERIALS BEC 'E~
SUSINE88 PLAN A8 A WHOLE 2
" FORM 2A
HAZ. MAT. DIV.
INSTRUCT[ ONS: ....
I.. To avo&d fun~heP ac[ton, Pe~urn ~h&s f~om ~t~h~n 3~ days
TYPE/PRINT 6NS~ERS [N EN6L[SH.
5. ~ns~e~ the quest&OhS belo~ for the business a5 a ~hote. "
4. · Be as bP&el and concise as po~slb!e.
5EOT[ON 1: BUSZNESS ~PENT[F[C~T~ON pRTA
B. LOCATION I STREET ADDRESS: )~ ~,~/~ ·
.SECTION 2: EMERGENCY NOTIFICATIONS
In case of an emergency involving ~he release or ~hreataned rale~se of
a hazardous Ma%eriml, call g,1,.1, and 1-8~-8S2-7~58 or I-B18-42?-434t. This
~il) no+.i~y your local fire dapartment and the State Office of EMergency
Services as required by law.
EMPLOYEES TO NOTIFY IN CASE OF EMEEGENOY:
N~ME 6NO TITLE DURING BUS. HRS. EFTER BUS. HRS.
~ECTION ~: LOCATION OF ~T~LITY SHUT-OFFS FOR BUSINESS RS ~ UHOLE
~. SPECIAL:
E. LOCK 8OX: YES / ~ IF YES, LOCATION:
ZF YES, DOES IT CONTAIN SITE P_A~.S? YES / NO MSBSS? YES / NO
FLOOR PLANS? YE~ / ¢'.t0 KEYS? YES / NO
SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE ,
SECTION S: LOCAL EMERGE.NCY MEDICAL ~tSS!STANCE FOR YOUR BUSINESS ASA WHOLE
SEOTION G~-. EHPLOYEE TRAINING
EMPLOYERS ARE REQUIREO TO HAVE ~ TRAINING PROGRAM WHICH PROVIDES EMPLOYEES
WITH INITIAL ANO REFRESHER TRAINING IN THE SEFE H~NDLING OF HEZAROOUS
MGTERIGLS. '
A. NUMBER OF EMPLOYEES AT THIS F~CILITY /
~. 00 YOU H~E uSos (M~TERZ~L S~FETY O~T~ SHEETS~ FOR E~CH H~Z~ROOUS
M~TE~Z~L YOU H~NOLE ~ ~Z~
C. GISE ~ BRIEF SUMMGRY OF Y~R HGZARDOUS MATER!~LS TRGINING PROGRGM:
SECTION ?: EXEMPTION REQUEST
i CERTIFY UNOER PENALTY OF PERJURY THAT MY BUSINESS IS EXEMPT FROM THE
REPORTING REQUIREMENTS OF CHAPTER G.BS OF THE CALIFORNIA HEALTH ANO SAFETY
COOE FOR THE FOLLOWING REASONS:
WE O0 NOT HANDLE HAZARDOUS MATERIALS.
WE O0 HANOLE HAZAROOUS MATERIALS, BUT THE QUANTITIES AT NO
TIME EXCEED THE MINIMUM REPORTING QUENTITIES.
OTHER (SPECIFY RE~SON)
SECTION 8: CERTIFICATION
I, (~/~ ~-,;~ , certify that the above information is
accurate. I understand that this information will be used to fulfill my
firM'5 obligations under the new California Health and Safety code on
Hazardous Materials (Div. 2~ Chapter ~.95 S~c. £SS00 Et Al.) ~nd that
inaccurate information constitutes pecjur~.
BAKERSFIELD Clef FiRE DEPARTMENT
2130 "G" STREET
BAKERSFIELD, CA 93301
OFFICIAL USE ONLY
...... BUS I NESS PLAN
"' :'"'" "" ................. -':" .....:" "" '"'"~"S"[' NGLE .~AC~'T'Li Ty ':'uNIT ...... :''
F Ol:~M 3.~
INSTRUCTIONS
,.-i.lj:~ ?.,.,.'~ :~',,XU~ :~(?'%,1. t~To avoid further':;action,.~'this ~orm must be returned by: '.
::~'"~fi. /TYPE/PRINT YOUR. ~SWERS' iN ENGLISH.
"' 8. Answer the questions below ~o~ THE ~ACtLITY' UNiT LISTED BELOW
· 4. Be as BRIEF and CONCISE aS possible.
FACILI~ ~IT~ FACILI~ ~IT N~:.
SECTION 1: ~ITIGATION~ PRE~ION~ AB~TE~EN~ PROCED~ES
SECTION 2: NOTIFICATION AND EVACUATION PRocEDuRES AT THIS UNIT ONLY
SECTION 3: HAZARDOUS MATERIALS FOR THIS UNIT ONLY
A, Does this Facility Unit ' ~ Haz.~rdous Mate_._ia~
E~ YES, see ~.
~¢ NO. continue ~th SECT;ON 4.
2 A,~, any of ='- hazardous ma'~e-4ajs ~ bona
"' ':'" I'f No, complete'a separate 'hazardous 'mater'ial's inventory .' '- ...... '"' : "'" .....
form marked: NON-TRADE SECRETS ONLY (white form =4A-l)
If Yes, complete a hazardous materials inventory form marked:
T~DE SECRETS .ONLY (yello, 'form 84A-2.) !n addition to. the non-t~ade .. .~.. .
. . SEOTZON 4: PRIVATE FIRE PROTEOTZON .,.5', ..... ' · .......... ~: '.
SECTION §: LOCATION OF WATER SUPPLY FOR USE BY EMERGENCY RESPONDERS
.SECTION. 6:..LOCATION OF UTILITY,. SHUT-.OFFS AT THIS.UNIT ONLY. ~'-~
B. ELECTRICAL:
............... . .... .... ,.. ........
C. WATER:
D. SPECIAL:
E. LOCK BOX: YES ./~ IF YES, LOCATION:
_ "'" YES NO, MSDS:-;? VES "NO
IF YES, SI=,: PLANS? /
FLOOR PLANS? YES ./ NO KEYS? YES ./ NO
CITY of BAKERSFIELD
NON--TRADE SECRETS ,
LOCATION: II~e~l,~l A ~ ADDRZSS: ~3~} ~a~e~cL~ STANDARD IND. CLASS CODE .~~
CITY, ZIP: ~~i~1 ~ ~t~ C~TY, Z~P: ~~'~ ,~ DUN AND BRADSTREET NUHB~R
PHONE
v~ veo.e ,: ~-~_ __ - ___ - ~___
I 2 3 I S t ? I ! 11 II I~ 13 Ii
[~e C~e ~t ~t Est ~its m Site I~ ~ Tm ~ .. St~ tn r~tlity ~ I~t~ti~
_~_I~I.Z~&..i~_I.__~ ..........,~~~ . ~ .......
Ph~ical ~ HNlth ~zl~ C.A.S. ~ ~ ~t II k i C.l S ~
:~ [~ - r-~ ~t 12 ~ C.A.S. ~
h of P~q Mlth
,P~ic~l ~ ~lth HIII~ C.A.S. ~ ~/~ ~t II M & C.A.S. ~
(C~k ~11 t~t ~ly)
~lth of ~ ~lth ~- '
~t 13 M&C.A.S. i
:zL_I L I i '1 ~. l I I I I .......................
P~Icol ~ ~lth ~zo~ C.A.S. i ~t II b I C.A.S. i
(C~k ~11 t~t o~iy)
- r--~ ~--~ -- r--~ ~t ~ ~&C.A.S. ~
HHIth of Pm~q ~lth
~t 13 ~ &C.A.S. ~
Y~ic~l ~ Hfllth ~Z~ C.A.S. ~ Wt I1 h i C.l.S. ~
(C~k ,11 tMt Mly)
- -- ~--~ v.--~ C~t 12 ~&C.A.S. ~
~-] Fine Hazard ~-a-~ ~tivity ~ ] ~1~ L_J ~ ~l~e ~-a lit.re
H~llh of Pr~lurl H~llh
~tl] ~ i C.A.S. ~
~E~G~NCY C~T~CTS II 12
~ . ' .... H ........ ~ ..... : ........ TlllI ~F'~! ......
Clrttficati~ (Read and si~ after completing all sections)
I c.rt~fy ~der ~lty of 1~ t~t I ~ve mrsmilly ex~in~ ~. fNiliir .tth t~ tnf~ti~ suWitt~ tn tht~ mil mttK~ ~tl, ~ t~t ~ ~
Ni i~-~HiE1;1-till;'Br~i~;)iBF'01-~i~7~Fit~'i'~Gl~Hi~i~F~lill;i Sl)~iIG~i ................................................ ~ti .............
BAKERSFIELD CITY FIRE DEPAR
2130 "G" STREET
BAKERSFIELD, CA 93301
(805) 32s-ag?9
OFFICIAL USE ONLY
HAZ ARDOL'S MATERi ALS
BUSINESSPORMPLAN 2AASA WHOLm~~~
INS~UCTIONS:
1. To avoid gurther action, return ~h~s foum b~
2. TYPE/PRINT ANSWERS IN ENGLISH.
3. Answer the questions below for the business as a whole.
4. Be as brief and concise as possible.
SECTION 1: BUSI~SS IDE~IFICATION DATA
SECTION 2: EMERGENCY NOTIFICATIONS
In case of an emergency involving the release or threatened release of a
hazardous material, call 911 and 1-800-852-7550 or 1-916-42?-4341. This will notify
your local fire department and the State Office of Emergency Services as required by
law.
EMPLOYEES TO NOTIFY IN CASE OF EMER6ENCY:
NAME AND TITBE DURING BUS. HRS. AFTER BUS. HRS.
SECTION.3: LOCATION OF UTILI~f Stfb~-OFFS FOR BUSINESS AS A :~HOLE
A. NAT. GAS/PROPANE:
B. ELECTRICAL:
C. WATER:
O. SPECIAL:
E. LOCK BOX: YES /' NO IF YES, LOCATION:
..... '~°~°~ ~,"~ S
~F YES DOES IT COYT~TX S~TE PLANS? YES / }~0 .,,ou~o: .- , .,
FLOOR PLANS? '/ES ,/ X0 KEYS? YES ,/
SECTION 4: PRIVATE RESPONSE TE.~M FOR BUSINESS AS A WHOLE
SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YOb~ BUSINESS AS A WHOLE
SECTION 6: EMPLOYEE TRAINING
EBiPLCYERS
REFRESHER TRAi~ING IN THE FOLLOWING AREAS.
CIRCLE YES OR NO INITIAL REFRESHER
A. METHODS FOR SAFE HANDLING OF HAZARDOUS
MATERIALS: ....................................... YES ~O YES NO
B. PROCEDURES FOR COORDINATING ACTIVITIES
WITH RESPONSE AGENCIES: .......................... YES NO YES ~0
C. PROPER USE OF SAFETY EQUIPMENT: .................. YES NO YES NO
D. EMERGENCY EVACUATION PROCEDURES: ................. - YES NO YES XO
E. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS: ....... YES NO YES NO
SECTION 7: HAZARDOUS MATERIAL
CIRCLE YES - NO - NONE
DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL tX QUANTITIES LESS THAN 500 ?OU'.7~OF A
SOLID, S5 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS: ...... ~ NO
I, ,- , certify that the above information is accurate.
I understand that this information wil.l.be used to fulfill my firm's obliyations under
the new California Heaith and Safety code on Hazardous Materials (Div. 20 Chapter 8.95.
Sec. 25500 Et Al.) and that inaccurate information constitutes perjury.
- 2B -
Dear Business Owner:
Enclosed piease find a cody of your res:onse to the Hazardous Material Business
Plan reques:. We have foun~ it necessary to reject your plan for ~he following
reason(s) as checked below.
~ Ille.~ible Business Plan (please print or type information i= E~gIish).
Fom 2A r"-T Missing or lr--'~nc°mple~e
Form 3A F/~issing or~'-~ Incomplete
This is to be correct'a~d~_Q~r~submitted within 30 days to:
Bakersfield City Fire Department
Hazardous Materials Division
2~30 "G" Street
BaKersfieId, CA 93301
If additional copies of any forms are needed they can be picked u: from the
Hazardous Materials Division at 2~30 "G" Street in person.
Sincerely Yours,/
Hazardous Materials Coordinator
REH/eg